Referring Physician Information

Request An Appointment
801-213-3599

Pediatrics is here to assist community physicians and specialists with consultation and referral services. To refer a patient, please complete the form below and fax all related clinic notes and diagnostic reports to the specialty fax number. If no fax or online referral form is listed you will need to call the division directly.

* Name:Office Contact:Department:Phone:Fax:* Email Address:Select One:Referring to:Urgency Rating:Would you like to request a specific provider?:Patient Name:University of Utah Health Medical Record Number (if known):Date of Birth (MM/DD/YYYY):Address:City:State:Zip Code:Secondary Phone:Policy Number:Policy Holder:Phone Number:Insurance Provider:Policy Number:Policy Holder:Phone Number:Insurance Provider:Enter Watermelon Here

For clinic notes and diagnostic reports

Specialty	Fax
General Pediatrics
Allergy & Immunology	801-587-7539
Behavioral Health
Cancer
Cardiology	801-587-7539
Diabetes & Endocrinology	801-587-7539
Gastroenterology	801-587-7539
Infectious Disease	801-585-3789
Medical Genetics/Metabolic	801-581-8986
Nephrology & Hypertension	801-587-7539
Neurology	801-587-7539
Ophthalmology	801-581-3357
Orthopaedics	801-581-4402
ENT (Otolaryngology)	801-585-2500
Physical Medicine & Rehab/ Comprehensive Care	801-587-7539
Plastic Surgery
Pulmonary Care & Sleep Medicine	801-587-7539
Rheumatology	801-587-7539
Surgery
Urology

Pediatrics

Referring Physician Information

801-213-3599